Eds. Note – Multnomah County and Healthshare Oregon have an acrimonious business relationship serving people with mental illness and addiction. In 2013 MultCo hired the Technical Assistance Collaborative to advise them about options for the future of managed care. Simply, the ACA privatizes public health, but private agencies may not be incentivized to care for high cost / low return patients. Meanwhile, our streets are filled with sick people unable to access worthwhile care. Last time TAC came to town (2001) the mental health system got turned upside down. This time the advise is to bulk up and get serious or quit the business. Their recent results are attached and below.

Mental Health and Addictions Services: Consultation on Managed Care and Local Mental Health Authority Functions and Operations – PowerPoint presentation for the Multnomah County Board (PDF)

Mental Health and Addictions Services: Consultation on Managed Care and Local Mental Health Authority Functions and Operations – full narrative text (PDF)

Multnomah County Commissioners meeting, June 24, 2014. Agenda – Human Services – Mental Health and Addictions Services: Managed Care and Local Mental Health Authority Roles in a Changing Healthcare Environment. Presenters: Susan Myers, Director County Human Services; David Hidalgo, Director – Mental Health and Addiction Services Division; and, Kelly English and Carol Gyurina, Technical Assistance Collaborative. (2 hrs)

Executive Summary

Summary of Findings and Recommendations

The Multnomah County Department of Human Services, Mental Health and Addiction Services Division (MHASD) engaged the Technical Assistance Collaborative (TAC) and its partner, the University of Massachusetts Medical School, Center for Health Law and Economics, (CHLE) to conduct an analysis of its dual role as the Local Mental Health Authority (LMHA) and a Risk Accepting Entity (RAE) as part of Health Share, one of the two Coordinated Care Organizations (CCOs) serving Multnomah County residents. The purpose of this engagement was to provide MHASD with an analysis of its local mental health authority and managed care functions in order to assist the County in making decisions regarding efficient management of resources and provision and/or administration of mental health services for Multnomah County residents. Additionally, TAC/CHLE was asked to help the County evaluate the risks and opportunities of continuing as a RAE in this evolving healthcare environment and what changes would be necessary to improve the County’s performance as a RAE should the County choose to continue in this role in the future.

The following recommendations resulted from this consultation:

Managed Care Recommendations

Financial systems and management

• If the County wants to remain as a RAE it will be critical that it invest in an accounting system that is designed to function for a managed care line of business.
• Accounting should set up a cost methodology to disaggregate full-time equivalent (FTE) positions and expenditures by payer and program type and a system to track each line of business.
• The amount of indirect and non-staff administrative costs allocated to managed care operations should be reviewed.
• The County should work with Health Share to establish common definitions of administrative duties and associated costs for clear tracking and reporting.
• Opportunities to maximize Medicaid revenue should be sought where possible by identifying those services currently being funded with state or county general fund dollars that could become Medicaid reimbursable.
• The County should consider using existing resources to hire an actuary to review its utilization data, and develop an adequate capitation rate. This would help the County understand whether the capitation rates offered by Health Share are sufficient.
• To meet the contracted Medical Loss Ratio (MLR) requirement, the County should reduce non-staff administrative costs and retained revenue, re-directing amounts toward funding of appropriate medical services.
• The County should consider negotiating for a MLR requirement of 85%, which is closer to industry standard, especially since the retained earnings are the County’s one protection against the financial risk of the contract.

Utilization management

• The County should engage Health Share in discussions about whether or not the substance use benefit should remain in the capitation of the physical health plans. Given that the substance use residential benefit is now being managed by the behavioral health RAEs and the high co-occurrence of mental health and substance use disorders, moving the substance use benefit into the capitation of the behavioral health RAEs may help improve coordination of care and more integrated community-based treatment options for these individuals, while reducing inappropriate utilization of psychiatric inpatient care.
• The County should move forward in the process of changing its UM processes for children enrolled in Wraparound so that the care coordinator will have the responsibility for authorizing care. This type of approach to care management and authorization for youth participating in high fidelity Wraparound is more consistent with best practice nationally.
• The capacity of the County’s Wraparound team should be expanded. The County should also work with Health Share and the Department of Human Services to explore how to train and certify more providers in Multidimensional Treatment Foster Care (MTFC) to help ensure that youth with mental health challenges involved with the child welfare system have access to alternatives to residential care. The County may want to collaborate with the Oregon Social Learning Center on these efforts.
• The County may want to consider taking a more global approach to UM by creating a full-time network manager position with responsibility for meeting with providers to review certain quality metrics and focusing more on overall provider performance for the different contracted services they provide.
• Additional resources should be dedicated to identifying and coordinating care for high utilizing members. Using a more global approach to a member’s care through an increased emphasis on care coordination rather than service specific UM again aligns more closely with the purpose and intent of healthcare transformation.
• The County should request that Health Share evaluate areas such as service utilization limitations and the medical necessity criteria of all of its RAEs to ensure compliance with the federal Mental Health Parity and Addiction Equity Act.

Provider payment

• Health Share and Multnomah County should ensure that solid base data is used in calculating case rates, and should be transparent with providers about how these rates are being developed. Opportunity for provider input should be incorporated into the process.

Leadership and staffing

• A key leadership staff person should be hired or assigned to be fully dedicated to managing the Medicaid program. This person needs to understand both the financial and operational aspects of running a Medicaid managed care plan.
• Positions dedicated to network management and care coordination should be created.

Legal and contractual

• County leadership should engage with their legal counsel to ensure they have a thorough understanding of their contract with Health Share particularly as it relates to financial risk, delegation of utilization management and provider contracting functions.

Local Mental Health Authority Recommendations

• Given the substantial challenges of funding cuts and ongoing demands for the safety net, MHASD leadership needs the time to focus its attention on fulfilling the LMHA mandated duties and on the effective operation of the Community Mental Health Program (CMHP). As suggested earlier, hiring a key leader to focus on the managed care operations will hopefully allow MHASD leadership to refocus their attention on the work of developing and maintaining the critical services the County provides under the auspices of the LMHA.
• The County should strengthen their relationship with new State Mental Health Director so as to improve communication and engage in problem-solving.
• The County should work with key partners to develop strategies to reduce the reliance on hospital emergency departments for people in psychiatric crisis. Strategies to consider including enhancing the Crisis Assessment and Treatment Center or the Urgent Walk-in Center to provide 24/7 availability and exploring the Alameda County, California model which has proven successful in drastically reducing hospital emergency department (ED) “boarding times” and inpatient hospitalization rates for people in behavioral health crisis.
• Educating hospital emergency department physicians about the use of Safety Holds when substance abuse appears to be at play, and establishing a payment mechanism for the holds would alleviate demands for mental health resources and result in better disposition for the clients.
• In its role as the LMHA, the County should engage Health Share and Family Care as the two CCOs serving Multnomah County Medicaid members to help create solutions and reduce barriers to treatment for people with co-occurring disorders to reduce inappropriate utilization of hospital emergency departments and inpatient mental health care.
• Increasing access to and availability of care coordination for people not eligible for Medicaid (including facilitating enrollment in Medicaid) to help them transition between levels of care could improve the system’s ability to more easily move individuals through a continuum of care and supports.
• Continue to monitor and improve access to outpatient treatment and community support services as more people seek care as a result of Medicaid expansion.
• Multnomah County may be better served by reestablishing dialogue with involved stakeholders to determine how to facilitate use of inpatient and jail diversion services, and the existing involuntary outpatient commitment criteria.
• Together with their partners, the County should continue to implement its 10-year plan to end homelessness with a specific focus on promoting effective strategies such as permanent supportive housing for people with serious mental illness.